Bare bone
An area of bone in the mouth not covered by gums that does not heal.
CONDITION / JAWS, MOUTH AND NECK
Osteonecrosis of the jaw.
Osteonecrosis of the jaw is a section of the jaw bone that has died and does not heal for a long time; it is often visible in the mouth as a bare bone. It can be drug-induced — after bisphosphonates or denosumab — and radiation-induced, after irradiation of the head and neck.
CONCEPTUAL VISUALIZATION- What it is
- The area of the jawbone is dead and does not heal; it is often seen in the mouth.
- Why
- Medicines that affect bone (bisphosphonates, denosumab), or radiation to the head and neck.
- How often
- In osteoporosis — 0.001–0.01%; at high doses in the treatment of cancer — 1–15%.
- How we treat
- Conservatively at first; if it does not help or the lesion is widespread, the dead bone is removed.
01 / WHAT IS ITWhat is
What is
osteonecrosis of the jaw.
Osteonecrosis is the death of a bone area. In the jaw, it manifests as bare bone in the mouth or a fistula—an opening in the gums or skin through which the doctor can feel the bone.
Drug-induced osteonecrosis is associated with drugs that affect bone: bisphosphonates (eg, zoledronic acid or alendronic acid), denosumab, and drugs that inhibit the growth of blood vessels. According to the MASCC/ISOO/ASCO guideline, this diagnosis is made when the bone is exposed or palpable through the fistula for more than 8 weeks, and the jaw has not been irradiated and has no metastases.
Radiation osteonecrosis, or osteoradionecrosis, is a complication of radiation therapy to the head and neck: the irradiated bone recovers more poorly.
The risk depends on why and in what dose the medicine is prescribed. In osteoporosis, it is very low, and the benefits of bone medications usually outweigh the risks. Do not stop the medicine on your own - it is up to the doctor who prescribed it.
This is general information. The doctor will tell you what will suit you after the examination.
02 / SIGNSHow
How
osteonecrosis presents.
If you are taking or have taken bisphosphonates or denosumab, or have had head and neck radiation, these changes in your mouth should be reported to both your doctor and your dentist.
Wound after tooth extraction
A hole after tooth extraction or a wound after jaw surgery does not heal for a long time.
Loose tooth
The tooth began to shake for no apparent reason.
Pain, swelling, ulcers
Pain or swelling in the mouth or jaw, ulcers on the mucous membrane.
Fistula
An opening in the gums or skin that may ooze pus.
Osteomyelitis of the jaw, fistula03 / REASONSWhy
Why
the bone dies.
People who are being treated for cancer with high doses of drugs that affect the bone are at the highest risk. What else matters:
Medicines for cancer
Bisphosphonates or denosumab in high doses — for bone metastases or myeloma. In an analysis of three studies of 5,723 patients with bone metastases, osteonecrosis developed in 1.3% on zoledronic acid and 1.8% on denosumab; the difference was not statistically significant.
Medicines for osteoporosis
The risk is estimated at 0.001–0.01% — slightly higher than in the general population (less than 0.001%).
Tooth extraction
In an analysis of 5,723 patients, 61.8% of those who developed osteonecrosis reported tooth extraction. Surgery on the jaws also increases the risk.
Irradiation
According to a meta-analysis of 6 studies, osteoradionecrosis developed in 8% after modern oral radiation therapy (IMRT) (certainty of the data is very low). It has been associated with postoperative exposure, doses greater than 50 Gy, and mandibular involvement.
Malignant tumors of the jawsOther factors
Glucocorticoids, diabetes, poor oral hygiene, chronic inflammation, rubbing dentures.
04 / SEEK MEDICAL ADVICE
When to seek medical advice?
Osteonecrosis itself usually does not require emergency care. But the infection from the affected bone can spread, and then help is needed immediately.
103 immediately if:
- it is difficult to breathe;
- difficulty speaking or swallowing;
- severe swelling in the mouth;
- swelling of the neck grows rapidly;
- it is difficult to open the mouth;
- the eye is swollen or painful, vision has suddenly deteriorated;
- very frequent breathing;
- confused consciousness, unclear speech;
- bluish, pale or mottled skin;
- very high or very low temperature, the body is hot or cold to the touch, chills;
- a rash that does not fade when pressed;
- bleeding from the mouth or from a wound that cannot be stopped.
Do not delay a visit to the doctor:
Immediately - to the surgeon who operated, and if it does not work - to the reception department: pain or swelling increases after jaw surgery. On the same day - to the doctor and dentist: you are taking or have taken bisphosphonates or denosumab or had radiation to the head and neck and have a loose tooth, ulcers, pain or swelling in your mouth or jaw; swelling and redness increase, pus flows or the temperature rises. Do not stop the medication on your own. Planned: a dental examination before starting such drugs or radiation, and every 6 months thereafter.
05 / DIAGNOSTICSHow to determine
How to determine
stage
- Talking about medicine
What drugs, how long and in what dose; whether the head and neck were irradiated; when the teeth were removed.
- Review
Bare bone or fistula, condition of gums and teeth. The stage should be determined by a doctor who has experience in the treatment of osteonecrosis.
- Pictures
Cone-beam CT shows the state of the bone with less exposure; an MRI, bone scan, or PET if necessary, although a plain X-ray is often sufficient.
- Exclude the tumor
If a person is being treated for cancer, it is important to make sure that there is no metastasis in the jaw: drug-induced osteonecrosis is diagnosed only when there is none.
- Coordination with doctors
The dentist, the surgeon and the doctor who prescribed the medicine (oncologist or endocrinologist) together decide what to do with the medicine and when to operate.
06 / TREATMENTHow we treat
How we treat
osteonecrosis
Treatment depends on the stage, size of the lesion, medications, and general health. The MASCC/ISOO/ASCO guideline advises starting with conservative measures; surgical removal of dead bone is used when the lesion is widespread and conservative treatment does not help.
01
Conservative treatment
The first step.
- Rinsing and antibiotics
- Conservative treatment — rinsing with antibacterial agents and antibiotics inside. In an analysis of 5,723 patients with bone metastases, more than 95% of patients with osteonecrosis were treated conservatively; at the time of analysis, osteonecrosis was healed in 36%.
- Hygiene and prostheses
- Poor oral hygiene and rubbing dentures increase the risk of osteonecrosis, so they should be monitored closely.
- A break in medication
- In a review of 33 studies, stopping bone-suppressing drugs was associated with better treatment outcomes. But whether to take a break or not is decided by the doctor who prescribed them: these drugs protect against fractures, and after denosumab withdrawal, most people's bones quickly lose density, and some develop multiple vertebral fractures.
02
Necrectomy
Removal of dead bone.
- What are they doing?
- The surgeon removes the dead bone (sequestrum) and closes the wound with mucosa. In a review of 33 studies, surgical treatment was associated with a better chance of healing.
- The results
- In a meta-analysis of 9 studies, 62.1% of patients (144 out of 232) recovered after surgery, and 28.8% (38 out of 132) after conservative treatment. But the difference was not statistically significant, and the authors rate the quality of the evidence as low.
- It depends on what
- According to the same review of 33 studies, lesions of the upper jaw and those where the dead bone had already separated healed better; worse — late stages and cancer patients, especially myeloma.
- Resection with recovery
- In case of widespread damage, a segment of the jaw is removed and restored with a free flap. According to a meta-analysis of 46 studies (1292 participants), after such reconstruction in osteoradionecrosis of the lower jaw, the flap did not heal completely in 3.1%.
03
Osteoradionecrosis
After irradiation of the head and neck.
- Surgery
- The 2024 ISOO-MASCC-ASCO guideline classifies surgical treatment recommendations as having a strong evidence base.
- Pentoxifylline and tocopherol
- Medicines prescribed by a doctor. In a review of 7 studies (211 patients), 126 patients were cured or significantly improved without other interventions; at 15, the disease progressed.
- Baro chamber
- The same guideline considers hyperbaric oxygenation largely unwarranted: there is little evidence. In two randomized trials (65 patients), after removal of dead bone, 70% of those treated with pressurized oxygen healed and 51% without, the difference did not reach statistical significance.
04
Prevention
- Before cancer drugs
- Complete examination by a dentist and dental treatment before starting medication; during treatment, planned operations on the teeth and jaw bone are avoided.
- With osteoporosis
- Dental examination every 6 months. Tell the dentist that you are taking this medicine: there is a very small risk of damage to the jaw when a tooth is extracted or implanted.
- Before irradiation
- Healthy teeth reduce the need for emergency treatment before radiation. In a review of 22 studies, tooth extraction before radiotherapy may be associated with a higher risk of osteoradionecrosis, but the difference was not statistically significant and the certainty of the evidence was very low. The dentist and oncologist decide which teeth to treat or remove before radiation.
07 / AT THE VALIKHNOVSKYI INSTITUTE
How
How
we treat it.
Restoration of the jaw, when a segment of it has to be removed due to osteonecrosis, is performed in the "New Face" direction at Dr. Valikhnovskyi's Institute of Surgery. The decision about medication — interruption or replacement of bisphosphonates and denosumab — is made by the doctor who prescribed them (oncologist or endocrinologist); the clinic is responsible for surgical reconstruction.
CLINIC SERVICE
A new face
Form, symmetry, facial expressions and functions after injuries, wounds, burns, removal of tumors and congenital changes.
View service
What we do for this condition
- CT and 3D planning — mirror CT modeling; based on the 3D model, surgical templates and individual implants are printed.
- Fibula flap — a fragment of the leg bone with its own vessels reproduces the lower or upper jaw.
- Individual implants — plates and fragments of the jaw made of titanium or PEEK based on the patient's 3D model.
- Radial forearm flap — a thin flap used to restore the mucous membrane and floor of the oral cavity.
Rostislav Valikhnovskyi
Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.
How treatment works with us
- Documents onlineSend a CT scan, a list of medications with doses and dates, statements about radiation - the doctor will evaluate the situation beforehand.
- ConsultationReview, evaluation of pictures; coordination with the doctor who prescribed the medicine.
- PlanIs conservative treatment enough, is surgery necessary, and does the jaw need to be restored?
- TreatmentThe scope defines the plan; if a segment of the jaw has to be removed, it is reconstructed according to a 3D plan.
- RecoveryFor some time, only soft or liquid food, thorough oral hygiene, regular examinations.
08 / QUESTIONS AND ANSWERSCommon
Common
questions
Short answers. What is right for you, the doctor will tell you during the consultation.
Should bisphosphonates be stopped to prevent osteonecrosis?
Independently - no. With osteoporosis, the risk of osteonecrosis is very low, and without medication, the risk of fractures increases. Whether a break is necessary is decided by the doctor who prescribed them.
Can I have a tooth extracted if I take this medicine?
Tell the dentist about the medicine in advance: he may suggest another treatment. During the treatment of cancer with high doses, planned operations on the teeth and jaw are avoided; whether to stop the medication before such an operation, the guideline considers it uncertain.
Can osteonecrosis heal without surgery?
Yes, in some people. In an analysis of 5,723 patients with bone metastases, more than 95% were treated conservatively, and 36% had healed osteonecrosis at the time of analysis.
When is surgery necessary?
When the lesion is widespread and conservative treatment does not help. According to a meta-analysis, after surgery the results are slightly better, especially in the later stages, but the quality of the evidence is low.
What is the difference between radiation osteonecrosis and drug-induced osteonecrosis?
The reason: radiation occurs in the bone that was irradiated, medicinal - due to drugs that affect the bone. In both cases, the dead bone may need to be removed; with radiation, pentoxifylline and tocopherol are also used.
Does the pressure chamber help?
There is little evidence. The 2024 guideline considers hyperbaric oxygenation in osteoradionecrosis largely unwarranted.
How to reduce the risk?
A dental check-up before starting medication or radiation, thorough oral hygiene and check-ups every 6 months. Tell your doctor and dentist immediately about any problems with your teeth or gums.
Sources
19 sources · guidelines, consensus, systematic reviews and NHSshowCollapse
- American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws—2022 UpdateJournal of Oral and Maxillofacial Surgery, 2022doi:10.1016/j.joms.2022.02.008 ↗
- Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice GuidelineJournal of Clinical Oncology, 2019doi:10.1200/JCO.19.01186 ↗
- Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensusJournal of Bone and Mineral Research, 2015doi:10.1002/jbmr.2405 ↗
- Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastasesAnnals of Oncology, 2012doi:10.1093/annonc/mdr435 ↗
- Surgical vs conservative treatment of medication-related osteonecrosis of the jaw: A complex systematic review and meta-analysisOral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2021doi:10.1016/j.oooo.2021.09.009 ↗
- Prognostic indicators in medication-related osteonecrosis of the jaw: A systematic review and meta-analysisOsteoporosis International, 2025doi:10.1007/s00198-025-07464-7 ↗
- Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ)Oral Diseases, 2024doi:10.1111/odi.14887 ↗
- Fracture risk and management of discontinuation of denosumab therapy: a systematic review and position statement by ECTSJournal of Clinical Endocrinology & Metabolism, 2020doi:10.1210/clinem/dgaa756 ↗
- Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO GuidelineJournal of Clinical Oncology, 2024doi:10.1200/JCO.23.02750 ↗
- The incidence of osteoradionecrosis of the jaws in oral cavity cancer patients treated with intensity-modulated radiotherapy: a systematic review and meta-analysisOral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2024doi:10.1016/j.oooo.2024.04.008 ↗
- Effect of preradiation dental intervention on incidence of osteoradionecrosis in patients with head and neck cancer: A systematic review and meta-analysisJournal of the American Dental Association, 2022doi:10.1016/j.adaj.2022.06.003 ↗
- Management of osteoradionecrosis of the jaws with pentoxifylline-tocopherol: a systematic review of the literature and meta-analysisInternational Journal of Oral and Maxillofacial Surgery, 2019doi:10.1016/j.ijom.2018.08.007 ↗
- Hyperbaric oxygen treatment of mandibular osteoradionecrosis: Combined data from the two randomized clinical trials DAHANCA-21 and NWHHT2009-1Radiotherapy and Oncology, 2022doi:10.1016/j.radonc.2021.11.021 ↗
- Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysisScientific Reports, 2024doi:10.1038/s41598-024-61862-1 ↗
- Side effects of alendronic acidNHS, 2025nhs.uk/medicines/alendronic-acid/side-effects-of-alendronic-acid ↗
- Common questions about alendronic acidNHS, 2025nhs.uk/medicines/alendronic-acid/common-questions-about-alendronic-acid ↗
- Dental abscessNHS, 2026nhs.uk/conditions/dental-abscess ↗
- SepsisNHS, 2026nhs.uk/conditions/sepsis ↗
- Cuts and grazesNHS, 2026nhs.uk/conditions/cuts-and-grazes ↗
The figures on the page are from these sources.
A bone in the mouth
does not heal?
Send a CT scan and a list of medications you are taking. The doctor will tell if an operation is needed and how to restore the jaw.